Hyde Park Neighborhood Club presents:

Coach Flem’s
Skills n’ Scrimmage
Basketball practice for 6th to 8th graders
Thursdays, 6-8 pm

Program Description
Open format practice ses-
sions, led by Coach James
Fleming.
Build age-appropriate skills
and sportsmanship through
drills and scrimmage.
Be in tip-top shape for
the Spring Youth Bas- Registration & Rules
ketball Leagues!

ALL youth must be registered

Additional Info
Absolutely no food in the
gym.
For more information, please
call the Neighborhood Club,
773.643.4062.
We’re located at 5480 S. Ken-
wood Ave, Chicago, IL 60615.
before going on the court!
Parent/guardians must be
present at time of enrollment.
Registrations must be com-
plete in order to play.
Proof of age required (birth
certificate/school ID).
$50 for 10-visit pass. Passes
expire 3 months from pur-
chase date.
ALL youth must sign-in each
time in order to play.
NO DROP INs or single-visit
passes.
 SKILLS N’ SCRIMMAGE
PLEASE NOTE: All applicable fields must be filled out or registration will not be accepted.

Child’s Name_________________________________________
Birthdate: ____________ Age: ____
**Proof of age required. Please photocopy and attach evidence. Acceptable forms of ID are birth certificate, government issued ID
passport, or school ID.
Gender: M F ___ African-American ___ Asian ___ Caucasian ___ Hispanic ___ Other
Guardian #1 Name: ___________________________________ Telephone: _____________ Cell: _____________
Address: ____________________________________________ Zip: _____ Email: _________________________
Relationship: __________________________________
Business Telephone No.: ______________________________ Work Hours: ______________________________
Guardian #2 Name: ___________________________________ Telephone: _____________ Cell: ____________
Relationship: ___________________________________
Address: ____________________________________________ Zip Code: ________ Email: _________________
Business Telephone No.: ______________________________ Work Hours: ______________________________
Emergency Contact: ____________________________________ Telephone No.: _________________________
Address: _____________________________________________ Relationship: ___________________________
Are there any medical conditions we should be aware of:?: _____________________________________________________
_____________________________________________________________________________________________________

I hereby give permission to the Hyde Park Neighborhood Club: (Initial if yes)

____ To arrange for emergency care through a clinic or a hospital in case of illness or accident.

____ To photograph, video, and or interview participant.

Date Paid: __________________
____ To use all photographs, videos and/or interviews.
Amount Paid: _______________
____ To post photograph/video on www.hpnclub.org
Receipt Number: _____________
____ To post interview or quotes on www.hpnclub.org

____ I understand by registering for these classes I am releasing the Neighborhood Club from
any liability for injury I may sustain due to my personal carelessness.

_____________________________________________________
Print Name

_____________________________________________________ ____________________
Signature Date